Deficiency Records for Spring Creek Rehabilitation and Nursing Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Spring Creek Rehabilitation and Nursing Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-01-26 | 2023-03-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-26 | 2023-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-03-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-26 | 2023-03-14 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-26 | 2023-03-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-26 | 2023-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-26 | 2023-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-26 | 2023-03-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-10 | 2022-10-22 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-16 | 2020-02-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-16 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-16 | 2020-01-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-16 | 2020-01-08 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-09-27 | 2018-10-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-27 | 2018-10-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-27 | 2018-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-10-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-27 | 2018-10-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-27 | 2018-10-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-09-27 | 2018-10-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-09-27 | 2018-10-27 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-27 | 2018-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-10-27 | N |
| Develop a communication plan. | Fire Safety | 2018-09-27 | 2018-10-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-27 | 2018-10-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-09-27 | 2018-10-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-09-27 | 2018-10-13 | N |
